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_ 17 - vol <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)/ CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> Q YES �ND REPORT BEEN FILED T OYES I HERESY CERTIFYTHATt. INFORMATION ACCORDING TO THE <br /> DISTR INSTRUCTION SHEET ON THE BACK PAGE OF is FORM <br /> REPORT DATE CASES <br /> u u � NED / D/ATE <br /> NAME OF INDIVIDUAL FILING AtPORT PHONE SONATUR <br /> w REPRESENTING O OWNER/OPERATOR Q REGIONAL BOARD COMPANY OR AGENCY E fir^ <br /> g �hOCAL AGEN O OTHER S• - GG• ®// I <br /> s , <br /> STREET cm STATE 9P <br /> J NAMEvQ` Gv� ��y �/ CONTACT PERSO[N��� PHON•E� <br /> `G. UNKNOWN GI��G�I/�� /-'G/•+GI•�[.� (IB/ )�� ^ <br /> a <br /> wADDRESS <br /> STREET Cm STATE I <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> o �.EJ G. <br /> a ADDRESS <br /> w VO GonREU CITY <br /> DRSS /SIZIP <br /> y CROSS STREET <br /> -�-d <br /> O LOCAL AGENCY AGENCY NAME CONTACT PERSON PHONE <br /> z �' <br /> w <br /> w 5. Cn P 6 v�6� lir) <FfS'o33 <br /> w� REGIONAL BOARD PHONE <br /> f <br /> y (1) NAME QUANTITY LOST(GALLONS) <br /> wp _ <br /> Z, .O 10.5',2 -•r/�L UNKNOWN <br /> m i (2) <br /> �- <br /> `A O UNKNOWN <br /> i DATE DISCOVERED p HOW DISCOVERED O INVENTORY CONTROL O SUBSURFACE MONITORING a NUISANCE CONDITIONS <br /> u D ( r r 0 TANK TEST TANK REMOVAL O OTHER <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> NKNOWN O REMOVE CONTENTS O CLOSE TANK&REMOVE O REPAIR PIPING <br /> 6 <br /> MI DI Yl V <br /> w <br /> 0 HAS DISCHARGE BEEN STOPPED? E]REPAIR TANK O CLOSE TANK&FILL IN PLACE O CHANGE PROCEDURE <br /> v <br /> o YES 0 NO IF YES,DATE u u .1 jr Y D REPLACE TANK Q OTHER <br /> SOURCE OF DISCHARGE CAUSE(S) <br /> ¢`j O TANK LEAK WN O OVERFILL a RUPTUREIFAILURE O SPILL <br /> O PIPING LEAK 0 OTHER u CORROSION a UNKNOWN O OTHER +(� <br /> yw CHECK ONE ONLY ( Lv <br /> O O UNDETERMINED Q SOIL ONLY Q GROUNDWATER 0 DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> wZ O NOACTIONTAKEN O PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED POLLUTION CHARACTERIZATION C <br /> �y O LEAK BEING CONFIRMED F-1 PRELIMINARY SITE ASSESSMENT UNDERWAY O POST CLEANUP MONITORING IN PROGRESS <br /> O O <br /> REMEDIATION PLAN O CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY v` <br /> CHECK APPROPRIATE ACTION(S) Q EXCAVATE E DISPOSE(ED) O REMOVE FREE PRODUCT(FP) O ENHANCED BIO DEGRADATION(IT) <br /> Isn S.c�RA OETusI <br /> In O <br /> O CAP SITE(CD) Q EXCAVATE&TREAT(ET) Q PUMPb TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w� <br /> w< 0 CONTAINMENT BARRIER(CB) NO ACTION REQUIRED(NA) El TREATMENT AT HOOKUP(HU) O VENT SOIL(VS) <br /> VACUUM EXTRACT(VE) O OTHER(OT) <br /> SoiG 5v <br /> w /Go' / 5r � ��f.�7 Y ,o"r��EQ��s� o�jZ, <br /> p <br /> G <br />